Gretna Health and Rehab: Fractured Finger Left Untreated - VA
The resident, identified in inspection records only as Resident #94, came to the facility's transitional care unit with the injury already documented. A medical professional who had seen the resident before the admission told inspectors the finger had been bandaged and splinted at the facility. The nursing staff who actually cared for Resident #94 told a different story, or no story at all.
The Interim Director of Nursing said she did not recall a splint being on the fractured finger. Inspectors then showed her a nursing progress note she had written herself, dated May 29. She said she did not recall documenting it.
Four other nurses identified as having cared for Resident #94 were no longer employed at the facility. Inspectors could not interview them.
The transitional care unit manager said she had pulled up Resident #94's photo in the clinical record. She could not recall the resident.
The wound care nurse, who was not working at the facility at the time of the resident's admission, explained what she would have done had she been there: she would have asked the medical provider for orders about a splint or treatment. The interim director of nursing said the protocol would be to notify the medical provider and wait for an order. The unit manager said she would have reviewed the admission paperwork, looked for any orthopedic recommendations, checked for follow-up ortho appointments, and called orthopedics directly if the treatment plan was unclear.
What any of them actually did for Resident #94 remained unresolved.
The inspection was a complaint investigation, conducted April 30, 2026. Inspectors reviewed the facility's own policy on physician's orders, which required that admission orders be provided for every patient at the time of admission and that a licensed nurse notify the physician to request those orders. The policy listed "other orders as indicated by patient's condition" as a required category.
There was no indication in the inspection report that Resident #94 received a physician's order for treatment of the fractured finger, a referral to orthopedics, or follow-up care of any kind during the stay.
The concern had been raised the evening before the inspection concluded, at a meeting on April 29 that included the interim administrator, assistant administrator, interim director of nursing, regional director of clinical services, and the regional president of operations. No further information was provided before inspectors left the facility the following day.
CMS rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. A broken finger that goes unsplinted and unordered does not produce headlines. It produces a resident who left a facility with an untreated fracture and a staff that, months later, could not piece together what had been done, by whom, or whether anything had been done at all.
The medical professional who saw the resident before admission remembered the splint. The nursing leadership at Gretna could not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gretna Health and Rehabilitation Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
GRETNA HEALTH AND REHABILITATION CENTER in GRETNA, VA was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records only as Resident #94, came to the facility's transitional care unit with the injury already documented.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.